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Between 16 and 20 June 2015 Vreerwerk will again organise a series of webinars on transgender and intersex developments on the human rights level. We will hold three webinars of two hours on the following themes:

Recent developments in the European trans* and intersex theatre. Where do they stand rights-wise? What can we learn from them to advance our national cause?

How can you use the UN to engage your government? What can we learn from good practices on both trans* and intersex?

How to use the Yogyakarta Principles of human rights on sexual orientation and gender identity and expression (SOGIE) issues in national advocacy?

The costs are 89 (incl VAT) euro per webinar, 239 (incl. VAT) for all three.

When interested send an e-mail to vreerwerk@xs4all.nl and we will get back to you as soon as possible. Or fill this form:

April 2015 is for trans* and intersex human rights in Europe a rather fortunate month. On the legal level that is. It still rains trans murders and suicides, not to speak of other atrocities. Which – cynically maybe – show precisely what we need that legislation for.

I want your attention for two cities in two countries for two different important advances. The first town is Valletta, on Malta. The other is Geneva in Switzerland. And then for two more where no less important stones fell in Oslo, Norway and Strasbourg, France. Continue reading

The United Nations have labelled April 7 World Health Day. A day to pay explicit attention to health issues. Since our focus is trans* and inter*, or differently (and more universally) put: gender identity, gender expression and sex characteristics, this is what we will look into.

Luxury

For transgender persons, or trans* people, or gender variant/diverse people, having a good health is often a luxury they cannot afford. Because they are not recognized as a group in need of specific health care (or even health care at). In many parts of the world including enlightened Europe, wishing to adapt your body’s sex characteristics is a frowned upon phenomenon. Both the general public and the medical sector may despise you for your needs.

Insurance

The next issue is getting the health care covered by insurance. Of the countries that provide health care to relieve the plight of trans* people, most cover maybe the ‘basics’ and then still often on extraneous conditions. These so-called basics are not by definition what the trans* person asks. Because being trans* does not only concern those people who need to ‘switch’ genders for their well-being, but every trans* person who is in need of any health care to increase their well-being with their gendered and sexed body. Some people may need hormone replacement therapy because their natal sex hormones don’t agree with them. Some need to only get rid of (the largest part of) their breasts. And given the choice, the percentage of trans* women that insists in getting rid of their original genitals is not that high. In the Netherlands only 12% of the whole trans* population (estimated at 2 to 3% of the population) decides for medical assistance. Communication from Spain indicates a similar percentage.

Fate

In most countries doctors don’t agree with prescribing hormones or doing surgery upon a patient unless a psychologist has done a thorough assessment of the care user’s mental health and observes the presence of “Gender Identity Disorder” or “Gender Dysphoria”. That process of establishing the diagnosis can easily aggravate the presupposed dysphoria (a word that actually refers to severe depression, and by virtue of that is not a good term). When left to the discretion of a prejudiced medical profession, that has no good understanding of sexual orientation and gender identity (and expression) phenomena, they will try to explain things away, but not legitimize the existence of gender diversity. The higher the level of morals conservatism, the higher the chance trans* people will meet this fate and only can progress medically assisted gender transition with a diagnosis of severe mental disorder.

Standards

Also in the progressive Netherlands you cannot easily enter medically assistance with gender transition. Where the Standards of Care for transgender health care states that informed consent is the way to go, the Amsterdam gender team still insists in a lengthy psychological evaluation and in case you may encounter practical trouble (intensifying ‘dysphoria’, growing life problems for non conforming ..) they may prolong evaluation or when already on HRT, suggest you to lower the dosage. As if that were the issue. Doing so leads to iatrogenic increase of mental instability. Which in turn leads to a decrease of the patient’s health.

Assessment

Another issue that weirdly is coupled to a trans* person’s health, is Legal Gender Recognition and the preconditions for that. In Europe 33 countries require psychological or medical interventions before recognizing a trans* person’s wish to change their gender assignment; 19 still require sterilization and genital realignment. Only two states in the world give the possibility to change one’s gender assignment with no strings attached: Argentina, and Malta. Denmark comes next, but still requires a half-year wait (and being over 18 y.o.). Everywhere else, where there are regulations, psychological assessment is the least invasive requirement, also in the Netherlands. Only two to three countries take trans* people seriously. And only one of these has provisions for a non-male/non-female reassignment.

Malta

Laws and regulations can have an important effect on trans and inter* persons’ well-being. They regulate the conditions for legal gender change, for medical assistance: which interventions are available at all, which ones are insurance funded? For intersex (or inter*, because it can also be an identity and those more ‘intergender’ and the asterisk in both inter* and trans* indicates a vastness in possibilities). Only one state in the whole world, one state out of more than 192 states, prohibits explicitly that sex characteristics get adapted to a social ideal of having genitals clearly distinguishable as male or female. Everywhere but in Malta this is still legal, and standing practice.Progress

Engaging in these usually non-consensual surgeries is a gross violation of a person’s dignity and personal autonomy. Intersex genital mutilations – usually performed on minors – equals forced sterilisation of women for belonging to the wrong ethnic group (forbidden by the European Human Rights Court en the UN!). When asked a paediatrician they sometimes agree that in the past many errors have been made, but nowadays medical science is so much better that the results are incomparable with the sorry state of technique and results of twenty-five years ago. By using that argument they still deny people their right to bodily autonomy, to decide for themselves about their body. They preclude being OK with those genitals (or gonads or chromosomes), with their body and their life.

Power

The health of a person considered physically or mentally deviant is the explicit object of power play, of medical, psychiatric and legal paternalistic laws and practices. That goes against the most basic rights and that alone already is pretty bad for one’s health.

International Day for Trans Depathologization, interview with Mauro Cabral, co-director of Global Activists for Trans* Equality

The news announces it this way: “For the first time in history, the World Health Organization (WHO) will throw out transsexuality from the chapter on ‘Mental and Behavioral Disorders’”. But (full) depathologization of gender diversity still seems a remote point on the horizon. What is good and what is better? We asked a key activist who helped create the Argentinian Gender Identity Law, a model for global policy. Mauro Cabral is co-director of Global Action for Trans* Equality (GATE), where he coordinates an international initiative to reform the Eleventh Edition of the International Classification of Diseases (ICD).

After two years of deliberation and pressure from depathologization activists, WHO recently removed the current diagnosis of “transsexualism” from the Mental and Behavioural Disorders chapter of its online [beta edition, transl.] version of the ICD-11, replacing it with a new category of “gender incongruence” in a new chapter on Sexual Health. Does this mean that trans people are not pathologized in the proposed classification? What does it mean, to “depathologize”?

For many trans advocates,depathologization is an emancipation struggle. The terminology itself also is contested. For some, it means full access to rights without any diagnostic requirement; for others, depathologization means eliminating diagnosis and medicalized control over individuals’bodies. There are tensions among advocates around the role of medicine in defining diverse trans experiences and around ownership of the body. Does the need for surgery and hormones represent a radical prosthetic incorporationwith medicine as the tool, or does it express conservative forms of technological expropriation of the body in alienating times of biocapital?1

Mauro Cabral summarizes it this way: “From one perspective, depathologization looks in a way like a Moebius band: striving for the maximal personal freedom seems to put the masking of biomedicine as regulatory principle for transition on the line; settling for less personal freedom risks perpetuation of current biomedical dogma, which diagnoses the wish to transition as personal and political pathology.”

There was a consensus in activism that transsexuality should no longer be considered as a mental illness by 2012. Now it is 2014, and this dream is still unmet. Is everything lost?

You are right. The world in which identifying as a gender different from the one assigned at birth is considered pathological did not end. However, in that time both the Diagnostic and Statistical Manual of Mental Illness (DSM) and the ICD went through an intense process of revision and reform.

What does this new version [of DSM] entail?

First, we need to clarify that, categorically, any diagnosis in the manual of mental disorders is by definition a mental disorder. Now they renamed “gender identity disorder” with an older clinical term of “gender dysphoria.” Where the previous diagnosis pathologizes trans people just for who they are, the “new” category can be seen as a step forward, because it puts the clinical focus on the trans specific experience of (the) suffering and stops when this disappears. In all the world materially or symbolically governed by the DSM and its codes, trans people stay trapped in one form or another of mental illness, and we continue to be cataloged as sufferers.

We need to remember that diagnosis in the DSM Manual is still a conditio sine qua non in many countries in the world, to access rights, like legal recognition and physical medical interventions.For example, the “treatment” for diagnosed suffering, that are still seen under this mark, and never as a biotechnologically mediated self expression.2

And in the case of the ICD reform?

The ICD Working Group called together by the World Health Organization agreed to reduce the scope of the diagnosis and proposed to scrap the current mental diagnostic categories that affect trans people, including “gender identity disorder” and “transvestic fetishism,” among others. This is fundamental: they finally recommended to remove any mention of trans issues in the chapter on mental health disorders. They also proposed new categories in a new non-psychiatric chapter on Sexual Health, including “gender incongruence of adolescents and adults,” and “gender incongruence in childhood”.

In what sense is the new category “gender incongruence” better than the previous?

“Gender identity disorder” is such a damaging diagnosis that almost any replacement category would be at least a bit better. In that sense, “gender incongruence” also avoids diagnosing trans people just for who they are, paying attention to the discomfort that the incongruence could cause between the gender identity and how it is embodied. However, obviously, you can only pathologize incongruence by implicitly invoking a cissexist ideal of (bodily, identitary or expressive) congruence. Also, incongruence is taxonomically linked to suffering and congruence is linked to happiness, with medical approval enjoyed by the congruent, but missing for the others. In other words, it is proposed that identifying as a gender different from the one they gave us at birth stops being a disorder (mental or otherwise), but now the possibility of living our gender in a non stereotypical, dissident, incongruent way could be in danger3.

Why then not fight for eliminating any diagnostic mention once and for all?

The answer is both ground for pride and pain: only one country in the world, ours, Argentina, admits access to legal gender recognition and transitional health services without requiring a diagnosis, psychiatric or otherwise. Denmark recently enacted a similar policy, but only for legal recognition. This means that, in the rest of the world,people who need to have their legal registration or their bodily configuration changed will still need a DSM or ICD code to access these modifications (every time that access not only means authorization but also public or private health coverage). None of these considerations, however, justify the introduction of the category, “gender incongruence of childhood.” Resisting this classification is a focus of our efforts.

But why pathologize trans children?

The simplest explanation is that gender diversity in childhood is still culturally unacceptable, but the “rational” arguments are different. One focuses on the anxiety that daddies and mommies of children, who rebel against social expectations around their sex, may have. So children are pathologized as therapy for adults. Another argument emphasizes diagnosis to facilitate expansion, funding and publication of research on gender diverse children. This argument is both perverse and faulty. There are decades of research and publication on homosexuality, which has long been depathologized. A third argument asserts that diagnosis guarantees inclusion [of gender diversity topics] in education, in a world where sex segregation is so naturalized and depoliticized, and where, sadly, a diagnostic framework still is considered more effective than a human rights framework. Last, both the old and the new diagnoses are justified as providing an archive of clinical history.

What would the function of this archive be?

Inasmuch as the first biotechnological transitional intervention is the administration of puberty hormone blockers, there are [experts] who consider a childhood diagnosis necessary for immediate access to treatment. This position universalizes the need for diagnosis, based on a treatment that is only available in a couple of countries, and it naturalizes that need. Unsurprisingly, the “gender incongruence in childhood” diagnosis is defended precisely by those medical teams that provide the treatment. Even worse, this argument installs hormone treatment as common fate, imposing early diagnosis as a way of ensuring later transition. As medical policy experts like Sam Winter and Simon Pickstone-Taylor have stated: it is obvious that those arguments fail at the hour of tending to the two biggest necessities of the children: to grow up in a world that does not impose normative forms of masculinity or femininity on them through submitting them to a diagnosis, and the need for information, support and containment.

If they eliminate the diagnostic criteria that pathologize gender diversity in childhood, what would happen with those trans children that need special health care?

The ICD already contains and will keep, non-pathologizing codes, that permit access to assessment and professional support when needed, without any diagnosis of physical or mental disorder. In those circumstances where treatment is needed for depression or anxiety of the child (oftentimes produced by hostility and rejection around them), the ICD already contains general codes that cover the issues4.

Can intersex also be approached from a depathologization perspective?

Without a doubt, although the processes and the issues are different. Approaching intersex from a depathologization perspective affirms bodily diversity, which should never be seen as a pathology. It also means the careful work of distinguishing in every intersex body those characteristics that need medical attention from those that don’t. Depathologization activism must also articulate the irreversible consequences of pathologization, including the chronic pain, the sterility, the mutilation and the genital insensitivity, post-surgical trauma, fistulas, chronic infections, and metabolic changes caused by surgical removal of the gonads or pharmacological treatments to “normalize” the body. This is the register of how pathologization makes us ill.

What impact do terms of “disorders of Sex Development” have on the fight to depathologize intersex?

Since the mid-1990s, the intersex movement has disputed the jurisdiction of biomedicine over intersexuality. Even the medical terminology evidences bias and cruelty. At the end of the 19th Century, mythological hermaphroditism was redefined as a category for clinical use and accompanied by many pseudo-hermaphroditisms to expand diagnostic range. By the mid-1920s, a more specialized vocabulary emerged with terminology about intersex bodies, although the old terms still remained. The struggle and success of the intersex movement in the 1990s, to depathologize intersexuality and to appropriate, subvert, and transform diagnostic intersex terminology into a political identity was answered in a new pathologizing attack.

In 2006, a new classification was created, that reorganized the spectrum of intersex bodies into a taxonomy of “Disorders of Sex Development.” As intersex researcher Georgiann Davis argued, this label reestablished medical authority over that jurisdiction in dispute: our bodies. A central aspect for the depathologization of intersex todayis resistance to the imposition of this vocabulary and its variations. For the intersex movement, there is an intrinsic relationship between nomenclature and treatment. Mirtha Legrand notes: “As they see you, so they treat you”. Advances in genetic and in fetal monitoring technology has extended the boundaries of medicalization to reach intersex embryos. They are often de-selected in preimplantation diagnostic procedures that promote selective abortion of intersex fetuses and prenatal drug administration to “prevent” the birth of intersex children.

Which are the political consequences of intersex pathologization?

Intersex activism itself is being psychopathologized and dismissed as a political symptom of disordered bodies. Because normalizing medical interventions usually take place in early childhood, intersex genital mutilation in infancy seems to infantilize the movement. In that way they mutilate our our capacity to be seen as adult activists with more than 20 years of experience in a sustained struggle. In spite of this oppression, the strong presence of intersex activism in regional and international human right systems has decisively contributed to the recognition of these medically unnecessary and non-consentual practices as forms of torture. Like medical abuse and forced, coerced or involuntary sterilization, these medical practices are violations of human rights.

What does depathologization mean for someone who like you lives the consequences of trans and intersex pathologization?

For years there was a prayer in the Spanish speaking world that affirmed:

“My body, primary territory of peace”

I would like to able to subscribe to that, one day. Today is not that day. As long as this war continues (or as I live), what remains of this body is my primary battleground.

This interview appeared first in Spanish in the Argentinian newspaper Página 12, on the occasion of the International Day for the Depathologization of Trans Identities, October 18, 2014

1Hence the question on who owns the body: if exterior criteria are to define what may happen with your your body, are you still the owner, or is it more a complex of medical and capital actors with their interests – owning shares in hormone producing companies or because of their research being paid by pharmaceutical companies? [transl.]

2 Like the remark about prosthetic use of medicine, this hints to self determination how one’s body should look and using medicine as a technical solution to get there.
[transl.]

3Not every trans/gender diverse person wants, needs or can live a “happy congruent” life. If there is a right to self determination, this extends to choosing not to submit to practices meant to become more congruent with society. The right extends to dissidence.
[transl.]

4These existing codes may be augmented with Z-codes, to clarify special needs of trans andgender diverse children(for example, when anxiety is caused by transphobic school bullying). [transl.]

On June 10 we will start the next online training “Fighting for trans* and intersex equality through human rights”. In five bi-weekly two hour webinars you will get information on the following themes:

You will learn how to use mostly the UN system and the European human rights system to influence the national government on implementing obligations they accepted by acceding to human rights treaties.

We will work with both material at hand and look forward to opportunities and obstructions for getting our rights realised. We will look at what can be done with existing material for local implementation and at the same time see that human rights are not a universal solution and have some inherent problems also.

The training comes at €150 (incl. VAT) for individual activists. If you come as a (funded) organization, the tariff is double to enable less well-off activists to participate. If this is still problematic, do send an e-mail and we’ll figure out a solution.

For more detailed info or alternatively participating in a live training, see this page. For registration or questions best send an e-mail to vreerwerk@xs4all.nl.

From the beginning of 2014 Vreerwerk will offer a training in human rights with a focus on transgender and intersex issues. This course aims at staff of government and inter-governmental and non-governmental organisations, students and activists interested in trans* and intersex issues that need a basis in human rights for their work, but are not looking for an expensive academic course. Continue reading

This week the Special Rapporteur on Torture of the UN released his report on torture in health care. A topic important for trans and intersex people. Thanks to two interventions of human rights advocates involuntary surgery now equals torture

November 8 is international Intersex Awareness Day. The objective is to attract attention for the rights of intersex people and the torture they have to undergo in many cases. Intersex people are people with rights. Rights that are being trodden as soon as your status is discovered. Intersex is the theatre of very strong medico-moral interventions. Since last century the debate fluctuates between acknowledging the intersex person’s feelings or the medical opinion, fixing sex in the direction the doctor thinks best or listening to the patient. Continue reading

There appears to be a growing awareness of intersex issues at the UN. The High Commissioner, Navi Pillay very recently mentioned intersex. Just a crumble still and a bit silly to have to cheer for that, but also: on this level things move (too) slowly. Sometimes the national level works fast, but sometime pressure form the UN or regional human rights bodies is needed. Continue reading

Vreerwerk

A Dutch name for thorough LGBTI advocacy and gender education. More than ten years on the theatre of transgender and human rights with an extra-ordinary personal story, I am the 'tranny' for your cause.